Comprehensive Pain Care
Is pain the only issue from which chronic pain patients suffer?
Comprehensive pain management requires that conditions which accompany chronic pain must also be addressed as failure to do so will predictably increase pain which may then increase the comorbidity which then increases the pain even further.
For example, insomnia increases pain with untreated pain increasing insomnia which then increases pain.
Similarly, treating the comorbidity often also decreases the pain, often minimizing opioid dosing.
What are common conditions that accompany chronic pain?
Insomnia, anxiety, mood depression, chronic fatigue, restless legs syndrome, and obesity not infrequently accompany chronic pain. As with the pain itself, some treatments are safe and effective and some treatments are dangerous. At office visits, Dr. Geller presents safe options and discusses published literature to support his views as this is what patients deserve when they place their trust in a physician.
Is insomnia simply insufficient duration of sleep?
No. Insomnia may be defined as insufficient duration of overall sleep, decreased deep sleep, or frequent awakenings.
Often frequent awakening insomnia reflects life threatening disorders known as obstructive sleep apnea in which the obstruction may reflect obesity impairing air flow. Alternatively, frequent awakenings may reflect increased risks for death from central sleep apnea in which the brain reflex to breath is suppressed as often occurs from alcohol, benzodiazepines, barbiturates, or improperly prescribed opioids.(Geller AS. Opioid overdose-related deaths. JAMA. 2011 July 27;306(4):379.)(Mogri M. Chest. 2008 Jun;133(6):1484-8.)(Farney. Chest. 2003 Feb;123(2):632-39.)
What is deep sleep?
Deep sleep is restorative REM and non-REM stage III and IV sleep. Deep sleep is high quality sleep. Benzodiazepines such as Ambien, Lunesta, Sonata, Valium, Klonopin, Xanax, Ativan,.... taken at night will increase duration of sleep by decreasing high quality sleep.
Medications such as Remeron, melatonin, Neurontin (nearly identical generically priced twin of Lyrica), cyproheptadine and other antihistamines, and baclofen may increase deep restorative sleep. The restless legs medications Requip and Mirapex may also enhance deep sleep duration.
Why is deep sleep important?
Deep sleep allows the brain to adjust cortisol, catecholamines, and other hormones which optimize white blood cell cancer scavenging function. Suppressing deep sleep may be the mechanism by which Ambien and other benzodiazepines consumed at night may increase risks for breast, lung, renal, and other cancers.(Geller, AS. Mayo Clinic Proceedings, 2012 Oct.)(Kripke. BMJ Open. 2012 Feb.)(Kao. Mayo Clinic Proceedings. 2012 May)
What are common conditions which may be caused by opioids but can be treated?
Opioid medications may cause constipation, nausea, sedation, hypogonadism, dry mouth, and itching side effects. When side effects occur, the patient should not be told that the treatment is terminated. Rather, different opioid medications may be offered or the side effect can be treated.
Should pain be relieved only with opioids?
The legitimate patient appreciates that the higher the opioid dose, the greater the risks for addiction. To minimize dosing and risks to the patient, nonopioid analgesics are characteristically desired by the legitimate patient who is not seeking to abuse the medication by unsafe dosing practices.
In fact, prescription controlled drug abuse is decreased nearly 50% from 17.8% down to 9% at attentive pain clinics where opioids are supplemental as opposed to clinics where opioids constitute the primary offering.(Manchikanti et al. Pain Physician. 2006;9:57-60.)
